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Insurance Plus Agencies - Progressive & GEICO Agent

Employment Application

Personal Information

First Name *

Last Name *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Employment Desired

Position

Date you can start

Salary Desired

When are you available to work?

General

Special Interests, Training or Skills

Former Employers

1.) Employer Name

1.) Employer Address

1.) Employer Phone Number

1.) Dates of Employment

1.) Reason For Leaving

2.) Employer Name

2.) Employer Address

2.) Employer Phone Number

2.) Dates of Employment

2.) Reason For Leaving

3.) Employer Name

3.) Employer Address

3.) Employer Phone Number

3.) Dates of Employment

3.) Reason For Leaving

References

1.) Reference Name & Phone Number

2.) Reference Name & Phone Number

Additional Information

Have you ever been dismissed or forced to resign from employment? *

If "Yes", Please Explain

Have you ever been arrested or charged with a criminal offense? *

If "Yes", Please Explain

Do you have reliable transportation? *

Authorization & Signature

“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.”

By typing my name here, I agree to the above Authorization. *

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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